Commission on Information and Communication Technology

NATIONAL TELECOMMUNICATIONS COMMISSION

COMMON CARRIER AUTHORIZATION DEPARTMENT
BIR Road, East Triangle, Diliman, Quezon City

Date : _________________________

APPLICATION FOR MODIFICATION OF RADIO STATION LICENSE

Name of Applicant/Licensee : _______________________________________________________
Office Address
: _______________________________________________________
CPCN/PA No.
: _______________________________________________________

1.) Station Callsign

2.) Class of Station
3.) Hours of Operation
4.) Location of Station
ADDRESS:

AUTHORIZED PARTICULARS

PROPOSED MODIFICATION

: ___________________________
: ___________________________
: ___________________________
: ___________________________

_________________________
_________________________
_________________________
_________________________

5.) Longitude
: ___________________________
Latitude
: ___________________________
6.) Frequency (ies)
: ___________________________
7.) Type of Emission : ___________________________
8.) Bandwidth
: ___________________________
9.) Directivity of Ant. : ___________________________
10.) Radio Equipment
Make/Type/Model
: ___________________________
Serial Number
: ___________________________
Power Output
: ___________________________
Cpacity
: ___________________________
11.) Service Area/Points Communications
: ___________________________
12.) Other Information : ___________________________

__________________________
__________________________
__________________________
__________________________
__________________________
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______________________________________
Signature over Printed Name
Authorized Reprentative
Name
PECE No.
PTR No.
Date Issued
Place Issued

: _________________________
: _________________________
: _________________________
: _________________________
: _________________________

WARNING:

Any witful false statement made on this application is punishable under article
183 of the Revised Penal Code by a maximum imprisonment of six (6) years.